Provider Demographics
NPI:1073565008
Name:PETTY, WILLIAM C (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:PETTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1702
Mailing Address - Country:US
Mailing Address - Phone:260-471-9466
Mailing Address - Fax:
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010387942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000092611OtherANTHEM
MI4074933100Medicaid
IN1696OtherPHP
OH2100621Medicaid
IN147380OMedicare ID - Type Unspecified
IN000000092611OtherANTHEM
INC43627Medicare UPIN
IN191150SMedicare ID - Type Unspecified
OHPE4111641Medicare ID - Type Unspecified
IN925240IMedicare ID - Type Unspecified
IN055740OMedicare ID - Type Unspecified
IN163520MMedicare ID - Type Unspecified
IN190320NMedicare ID - Type Unspecified
MI4074933100Medicaid